October 01, 2004
2 min read

Improper billing for extended ophthalmoscopy

Two codes cover extended ophthalmoscopy, a unilateral service that requires a thorough retinal drawing.

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Dr. M, a retina specialist, received a letter from Medicare stating that her use of extended ophthalmoscopy exceeded the expected frequency when compared with her peers. Initially, this did not alarm her; both her subspecialty training and the nature of her patient base supported the fact that she performed detailed retina examinations more frequently than general ophthalmologists. Concerned about future inquires by Medicare, however, the practice administrator examined a sample of 50 medical records and claims for extended ophthalmoscopy.

The review uncovered a general misunderstanding of these codes (92225, 92226) by the physician and billing staff. Problems existed in both documentation of the service and in billing. Several medical records in the sample contained no retinal drawing, some had very sketchy drawings of the posterior pole, and other records contained drawings labeled as “normal fundus.” Additionally, the physician used only CPT code 92225; 92226 did not appear on her route slip. Finally, the practice computer system had been programmed to append modifier –50 to all claims for extended ophthalmoscopy, which meant all claims were billed as bilateral services.

What problems exist with respect to the billing?

The practice had failed to follow the detailed instructions contained in the local medical review policy for extended ophthalmoscopy. Under the heading “What Is It?” the LMRP reads: “Extended ophthalmoscopy is a detailed examination and drawing that goes beyond the standard funduscopy of an office visit. Not every fundus exam qualifies as extended ophthalmoscopy. CPT states, routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated. It is a non-itemized service and is not reported separately.”

This service is indicated for a wide range of posterior segment pathology when the level of examination is greater than that required for routine ophthalmoscopy. Extended ophthalmoscopy is reserved for serious retinal pathology. While documentation requirements vary among Medicare carriers, all carriers demand a retinal drawing. The drawing should be large enough to include sufficient detail.

Two codes exist in CPT to identify extended ophthalmoscopy: code 92225 (Ophthalmoscopy, extended, with retinal drawing (ie, for retinal detachment, melanoma), with interpretation and report; initial) and 92226 (subsequent). No distinction is made between new and established patients. CPT 92225 is used for the initial exam on a particular retinal condition. Thereafter, documentation of the subsequent service (92226) should include evidence of a change in the condition (eg, worsening or progressing) that warrants a repeated examination.

Extended ophthalmoscopy is considered a unilateral service. Separate reimbursement is made for each eye when performed bilaterally. Specific patient conditions dictate whether a unilateral or bilateral service is needed. Not all claims for extended ophthalmoscopy are bilateral. While it is common practice for physicians to perform retinal exams on both eyes, if the pathology is limited to one eye, the extended ophthalmoscopy should not be billed for both eyes. Documenting a normal fundus for the fellow eye does not support a claim for extended ophthalmoscopy.

For Your Information:
  • Mary Pat Johnson, COMT, CPC, COE, can be reached at Corcoran Consulting Group, 1845 Business Center Drive, Suite 108, San Bernardino, CA 92408; 800-399-6565; fax: 909-890-1333; Web site: www.corcoranccg.com.